Trauma Transfer

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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Whit F., M.D. -

This was all great information that everyone should have to hear. One thing I would add: never delay a transfer because someone is still getting paperwork together. You can always fax t-sheets, face sheets, copies of ekgs, etc. after the patient has already been shipped.

Here's a question: if a patient REQUESTS a transfer that is not medically necessary to a hospital that they prefer, is the accepting physician liable for any adverse events that occur during the transfer? My current hospital insists that any stable patient who requests a transfer be accepted by the ED attending, even if we will not be providing specialized care. For example, a stable admitted pneumonia patient at Hospital X can request transfer to my hospital, and I'm supposed to always accept this transfer. If the patient dies in the ambulance, am I liable because I agreed to the patient's request for transfer, even though it was not for a higher level of care?

Howard M. -

Any transfer from an emergency department is covered under EMTALA. A patient may request a transfer to another institution, and it appears from the wording of the statute that this request takes the place of the physician's certification in the usual EMTALA paperwork. The transfer must still be an "appropriate transfer", however, and some regulatory provisions apply. Those regulations require that the request for the transfer must be made in writing; that the patient be advised of the hospital's EMTALA obligations; and that the patient be advised of the risk of transfer. The written request must include a statement of the risks and benefits of transfer, and the reasons for the requested transfer. 42 CFR 489.24(e)(1)(ii)(A). As for liability, EMTALA places the responsibility on the transferring hospital to ensure that the statute's requirements are met including that the be accompanied by "qualified personnel and transportation equipment" [Section 1395dd(c)(2)(D)]. Nothing in that statute will prevent you from being named in the suit, but the responsibility is clearly on the sending hospital until the patient arrives at your facility (arrival as defined by EMTALA).

Michael A., MD -

Hello from Atlantic Canada. This was a great review of the basics, of being aware of your facilites limitations, but also recognizing the essentials that all must be able to do. I live in a predominantly rural province. We have a provincial trauma program to ensure that EMS takes the right patient to the right facility. The program facilitates interhospital transfersas well.
Our Trauma Program is now availing all of our smaller facilites the Rural Trauma Team Development Course(RTTDC). It is a product of the ACS the makers of ATLS(Iknow, I know). ATLS is physician oriented. In large centres with many resources including staff. All are generally well experienced and aware of roles.Well in small ERs such is not the case. The RTTDC is aimed at MDs, PAs,NPs,RNs,LPNs, RTs, even housekeeping! In a trauma, all involved have to be able to recognize, effectively communicate, and have the ability to initiate to ensure all issue related to the ADCDE's are found and dealt with. With limited resources, there is no place for rigid defined roles, job descriptions, hierarchy. All of my non physician colleagues who took the course thought it was excellent opened there eyes, learned so much about recognizing and resusing the ABC's.

This RTTDC is layed out almost exactly like this talk. Anyone in small centers with limited resources, this is an excellent program. And they do emphasize knowing early the need for tranfer and being able to recogize the must do's, what not to waste time on and how effectively communiate.

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